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MassHealth
Transmittal Letter AOH-41
November 2017
TO: Acute Outpatient Hospitals Participating in MassHealth
FROM: Daniel Tsai, Assistant Secretary for MassHealth
RE: Acute Outpatient Hospital Manual 2017 HCPCS Code Updates and List of Revenue Codes Added to Subchapter 6
This letter transmits the following changes to the Acute Outpatient Hospital Manual:
• Subchapter 6 was amended to update the list of nonpayable Current Procedural Terminology (CPT) service codes in Section 602, and payable Level II Healthcare Common Procedure Coding System (HCPCS) service codes in Section 603 to reflect HCPCS updates issued by the Centers for Medicare & Medicaid Services for 2017; and
• Billable revenue codes previously listed in Appendix F of the Acute Outpatient Hospital Manual were incorporated into the new Section 605 of Subchapter 6 and Appendix F, itself, was retired.
The revised Subchapter 6 is effective for dates of service on or after January 1, 2017.
MassHealth Website
This transmittal letter and attached pages are available on the MassHealth website at masshealth.
Questions
If you have any questions about the information in this transmittal letter, please contact
the MassHealth Customer Service Center at 1-800-841-2900, email your inquiry to providersupport@, or fax your inquiry to 617-988-8974.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Acute Outpatient Hospital Manual
Pages vi and 6-1 through 6-24
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Acute Outpatient Hospital Manual
Pages vi and 6-1 through 6-16 — transmitted by Transmittal Letter AOH-38
Pages F-1 through F-6 — transmitted by Transmittal Letter AOH-23
6. Service Code
601. Introduction 6-1
602. Nonpayable CPT Codes 6-1
603. Payable Level II HCPCS Codes 6-11
604. Modifiers 6-13
605. Revenue Codes 6-17
Appendix A. Directory A-1
Appendix C. Third-Party-Liability Codes C-1
Appendix D. Utilization Management Program D-1
Appendix E. Admission Guidelines E-1
Appendix F. Reserved
Appendix T. CMSP-Covered Codes T-1
Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider Preventable Conditions……………………………………………………………………………… U-1
Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions……………….. V-1
Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity Schedules. W-1
Appendix X. Family Assistance Copayments and Deductibles. X-1
Appendix Y. EVS Codes/Messages Y-1
Appendix Z. EPSDT/PPHSD Screening Services Codes Z-1
601 Introduction
MassHealth providers must refer to the official list of Healthcare Common Procedural Coding Systems (HCPCS) codes and descriptions posted on the Centers for Medicare & Medicaid Services HCPCS website when billing for services provided to MassHealth members. For a list of billable revenue codes that may be used by acute outpatient hospitals (AOHs), please refer to Section 605 of this subchapter.
CPT Codes
MassHealth pays for services billed using all medicine, radiology, laboratory, surgery, and anesthesia Current Procedural Terminology (CPT) codes in effect at the time of service, except for those codes listed in Section 602 of this subchapter, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000, and in the current Acute Hospital Request for Application.
Level II HCPCS Codes
MassHealth pays for services billed using only those Level II HCPCS codes listed in Section 603 of this subchapter that are in effect at the time of service, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application.
Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT)
An acute outpatient hospital provider may request prior authorization (PA) for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Acute Outpatient Hospital Manual.
602 Nonpayable CPT Codes
MassHealth does not ordinarily pay for services billed under the following codes and code ranges.
0001F
0005F
0012F
0014F
0015F
4002F
4006F
4009F
4011F
0016T
0017T
0019T
0030T
0042T
0048T
0050T
0051T
0052T
0053T
0071T
0072T
0073T
0075T
0076T
0078T
0079T
0080T
0081T
0085T
0092T
0095T
0098T
0100T
0101T
0102T
0104T
0105T
0106T
0107T
0108T
0109T
0110T
0111T
0124T
0126T
0130T
0140T
0141T
0142T
0143T
0155T
0156T
0157T
0158T
0159T
0160T
0161T
0163T
0164T
0165T
0166T
0167T
0168T
0169T
0171T
0172T
0173T
0174T
0175T
0176T
0177T
0178T
0179T
0180T
0181T
0183T
0184T
0185T
0186T
0187T
0188T
0189T
0190T
0191T
0192T
0193T
0195T
0196T
0197T
0198T
0199T
0200T
0201T
0202T
0203T
0204T
0205T
0206T
0207T
0219T
0220T
0235T
0254T
0255T
0266T
0281T
0293T
0294T
0309T
0312T
0345T
0375T
00100
through
01999
10040
11004
11005
11006
11008
11922
11950
11951
11952
11954
15756
15757
15758
15781
15782
15783
15786
15787
15788
15789
15792
15793
15819
15824
15825
15826
15828
15829
15847
15876
15877
15878
15879
16036
17340
17360
17380
19271
19272
19305
19306
19316
19355
19361
19364
19367
19368
19369
19396
20660
20661
20664
20802
20805
20808
20816
20824
20827
20838
20930
20931
20936
20937
20938
20955
20956
20957
20962
20969
20970
20985
21045
21120
21121
21122
21123
21125
21127
21141
21142
21143
21145
21146
21147
21151
21154
21155
21159
21160
21172
21179
21180
21182
21183
21184
21188
21193
21194
21196
21245
21246
21247
21248
21249
21255
21256
21268
21343
21344
21346
21347
21348
21366
21386
21387
21395
21422
21423
21431
21432
21433
21435
21436
21510
21615
21616
21620
21627
21630
21632
21705
21740
21750
21825
22010
22015
22110
22112
22114
22116
22206
22207
22208
22210
22212
22214
22216
22220
22222
22224
22226
22318
22319
22325
22326
22327
22328
22526
22527
22532
22533
22534
22548
22552
22554
22556
22558
22585
22586
22590
22595
22600
22610
22630
22632
22633
22634
22800
22802
22804
22808
22810
22812
22818
22819
22830
22840
22841
22842
22843
22844
22845
22846
22847
22848
22849
22850
22852
22855
22856
22857
22858
22861
22862
22864
22865
23200
23210
23220
23335
23472
23474
23900
23920
24900
24920
24930
24931
24940
25900
25905
25909
25915
25920
25924
25927
26551
26553
26554
26556
26992
27005
27025
27030
27036
27054
27070
27071
27075
27076
27077
27078
27090
27091
27120
27122
27125
27130
27132
27134
27137
27138
27140
27146
27147
27151
27156
27158
27161
27165
27170
27175
27176
27177
27178
27179
27181
27185
27187
27215
27217
27218
27222
27226
27227
27228
27232
27236
27240
27244
27245
27248
27253
27254
27258
27259
27268
27269
27280
27282
27284
27286
27290
27295
27303
27365
27445
27447
27448
27450
27454
27455
27457
27465
27466
27468
27470
27472
27477
27479
27485
27486
27487
27488
27495
27506
27507
27511
27513
27514
27519
27535
27536
27540
27556
27557
27558
27580
27590
27591
27592
27596
27598
27645
27646
27702
27703
27712
27715
27724
27725
27727
27880
27881
27882
27886
27888
28800
28805
31225
31230
31290
31291
31360
31365
31367
31368
31370
31375
31380
31382
31390
31395
31584
31587
31725
31760
31766
31770
31775
31780
31781
31786
31800
31805
32035
32036
32096
32097
32098
32100
32110
32120
32124
32140
32141
32150
32151
32160
32200
32215
32220
32225
32310
32320
32440
32442
32445
32480
32482
32484
32486
32488
32491
32501
32503
32504
32505
32506
32507
32540
32650
32651
32652
32653
32654
32655
32656
32658
32659
32661
32662
32663
32664
32665
32666
32667
32668
32669
32670
32671
32672
32673
32674
32800
32810
32815
32820
32850
32851
32852
32853
32854
32855
32856
32900
32905
32906
32940
32997
33015
33020
33025
33030
33031
33050
33120
33130
33140
33141
33202
33203
33236
33237
33238
33243
33250
33251
33254
33255
33256
33257
33258
33259
33261
33265
33266
33300
33305
33310
33315
33320
33321
33322
33330
33361
33362
33363
33364
33365
33366
33367
33368
33369
33335
33400
33401
33403
33404
33405
33406
33410
33411
33412
33413
33414
33415
33416
33417
33418
33420
33422
33425
33426
33427
33430
33460
33463
33464
33465
33468
33470
33471
33474
33475
33476
33478
33496
33500
33501
33502
33503
33504
33505
33506
33507
33510
33511
33512
33513
33514
33516
33517
33518
33519
33521
33522
33523
33530
33533
33534
33535
33536
33542
33545
33548
33572
33600
33602
33606
33608
33610
33611
33612
33615
33617
33619
33620
33621
33622
33641
33645
33647
33660
33665
33670
33675
33676
33677
33681
33684
33688
33690
33692
33694
33697
33702
33710
33720
33722
33724
33726
33730
33732
33735
33736
33737
33750
33755
33762
33764
33766
33767
33768
33770
33771
33774
33775
33776
33777
33778
33779
33780
33781
33782
33783
33786
33788
33800
33802
33803
33813
33814
33820
33822
33824
33840
33845
33851
33852
33853
33860
33863
33864
33870
33875
33877
33880
33881
33883
33884
33886
33889
33891
33910
33915
33916
33917
33920
33922
33924
33925
33926
33930
33933
33935
33940
33944
33945
33946
33947
33948
33949
33951
33952
33953
33954
33955
33956
33957
33958
33959
33962
33963
33964
33965
33966
33967
33968
33969
33970
33971
33973
33974
33975
33976
33977
33978
33979
33980
33981
33982
33983
33984
33985
33986
33987
33988
33989
33990
33991
33992
33993
34001
34051
34151
34401
34451
34502
34800
34802
34803
34804
34805
34806
34808
34812
34813
34820
34825
34826
34830
34831
34832
34833
34834
34841
34842
34843
34844
34845
34846
34847
34848
34878
34900
35001
35002
35005
35013
35021
35022
35045
35081
35082
35091
35092
35102
35103
35111
35112
35121
35122
35131
35132
35141
35142
35151
35152
35182
35189
35211
35216
35221
35241
35246
35251
35271
35276
35281
35301
35302
35303
35304
35305
35306
35311
35331
35341
35351
35355
35361
35363
35371
35372
35390
35400
35450
35452
35501
35506
35508
35509
35510
35511
35512
35515
35516
35518
35521
35522
35523
35525
35526
35531
35533
35535
35536
35537
35538
35539
35540
35556
35558
35560
35563
35565
35566
35570
35571
35583
35585
35587
35600
35601
35606
35612
35616
35621
35623
35626
35631
35632
35633
35634
35636
35637
35638
35642
35645
35646
35647
35650
35654
35656
35661
35663
35665
35666
35671
35681
35682
35683
35691
35693
35694
35695
35697
35700
35701
35721
35741
35800
35820
35840
35870
35901
35905
35907
36415
36416
36468
36591
36592
36598
36660
36823
37127
37140
37145
37160
37180
37181
37182
37215
37218
37616
37617
37618
37660
37765
37766
37788
38100
38101
38102
38115
38380
38381
38382
38562
38564
38724
38746
38747
38765
38770
38780
39000
39010
39200
39220
39499
39501
39503
39540
39541
39545
39560
39561
39599
41130
41135
41140
41145
41150
41153
41155
41870
41872
42426
42845
42894
42953
42961
42971
43045
43100
43101
43107
43108
43112
43113
43116
43117
43118
43121
43122
43123
43124
43135
43279
43282
43283
43300
43305
43310
43312
43313
43314
43320
43325
43327
43328
43330
43331
43332
43333
43334
43335
43336
43337
43338
43340
43341
43351
43352
43360
43361
43400
43401
43405
43410
43415
43420
43425
43460
43496
43500
43501
43502
43520
43605
43610
43611
43620
43621
43622
43631
43632
43633
43634
43635
43640
43641
43644
43645
43752
43770
43771
43772
43773
43774
43775
43800
43810
43820
43825
43832
43840
43842
43843
43845
43846
43847
43848
43850
43855
43860
43865
43880
43881
43882
44005
44010
44015
44020
44021
44025
44050
44055
44110
44111
44120
44121
44125
44126
44127
44128
44130
44132
44133
44135
44136
44137
44139
44140
44141
44143
44144
44145
44146
44147
44150
44151
44155
44156
44157
44158
44160
44187
44188
44202
44203
44204
44205
44206
44207
44208
44210
44211
44212
44213
44227
44300
44310
44314
44316
44320
44322
44345
44346
44602
44603
44604
44605
44615
44620
44625
44626
44640
44650
44660
44661
44680
44700
44715
44720
44721
44800
44820
44850
44899
44900
44950
44955
44960
45110
45111
45112
45113
45114
45116
45119
45120
45121
45123
45126
45130
45135
45136
45395
45397
45400
45402
45540
45550
45562
45563
45800
45805
45820
45825
46705
46710
46712
46715
46716
46730
46735
46740
46742
46744
46746
46748
46751
47010
47015
47100
47120
47122
47125
47130
47133
47135
47140
47141
47142
47143
47144
47145
47146
47147
47300
47350
47360
47361
47362
47380
47381
47400
47420
47425
47460
47480
47550
47570
47600
47605
47610
47612
47620
47700
47701
47711
47712
47715
47720
47721
47740
47741
47760
47765
47780
47785
47800
47801
47802
47900
48000
48001
48020
48100
48105
48120
48140
48145
48146
48148
48150
48152
48153
48154
48155
48160
48400
48500
48510
48520
48540
48545
48547
48548
48551
48552
48554
48556
49000
49002
49010
49020
49040
49060
49062
49203
49204
49205
49215
49220
49255
49412
49425
49428
49605
49606
49610
49611
49900
49904
49905
49906
50010
50040
50045
50060
50065
50070
50075
50100
50120
50125
50130
50135
50205
50220
50225
50230
50234
50236
50240
50250
50280
50290
50300
50320
50323
50325
50327
50328
50329
50340
50360
50365
50370
50380
50400
50405
50500
50520
50525
50526
50540
50545
50546
50547
50548
50600
50605
50610
50620
50630
50650
50660
50700
50715
50722
50725
50727
50728
50740
50750
50760
50770
50780
50782
50783
50785
50800
50810
50815
50820
50825
50830
50840
50845
50860
50900
50920
50930
50940
51060
51525
51530
51550
51555
51565
51570
51575
51580
51585
51590
51595
51596
51597
51701
51702
51800
51820
51840
51841
51845
51860
51865
51900
51920
51925
51940
51960
51980
53415
53448
54125
54130
54135
54332
54336
54390
54411
54417
54430
54535
54650
55605
55650
55801
55810
55812
55815
55821
55831
55840
55842
55845
55862
55865
55866
56630
56631
56632
56633
56634
56637
56640
57110
57111
57112
57270
57280
57296
57305
57307
57308
57311
57531
57540
57545
58140
58146
58150
58152
58180
58200
58210
58240
58267
58275
58280
58285
58293
58400
58410
58520
58540
58548
58605
58611
58700
58720
58740
58750
58752
58760
58822
58825
58940
58943
58950
58951
58952
58953
58954
58956
58957
58958
58960
58970
58974
58976
59070
59072
59120
59121
59130
59135
59136
59140
59325
59350
59412
59514
59525
59620
59830
59850
59851
59852
59855
59856
59857
59897
60254
60270
60505
60521
60522
60540
60545
60600
60605
60650
61105
61107
61108
61120
61140
61150
61151
61154
61156
61210
61250
61253
61304
61305
61312
61313
61314
61315
61316
61320
61321
61322
61323
61332
61333
61340
61343
61345
61450
61458
61460
61480
61500
61501
61510
61512
61514
61516
61517
61518
61519
61520
61521
61522
61524
61526
61530
61531
61533
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61580
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61590
61591
61592
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61597
61598
61600
61601
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61624
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61680
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61690
61692
61697
61698
61700
61702
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61711
61735
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61751
61760
61850
61860
61863
61864
61867
61868
61870
62005
62010
62100
62115
62117
62120
62121
62140
62141
62142
62143
62145
62146
62147
62148
62161
62162
62163
62164
62165
62180
62190
62192
62200
62201
62220
62223
62256
62258
62287
63043
63044
63050
63051
63076
63077
63078
63081
63082
63085
63086
63087
63088
63090
63091
63101
63102
63103
63170
63172
63173
63180
63182
63185
63190
63191
63194
63195
63196
63197
63198
63199
63200
63250
63251
63252
63265
63266
63267
63268
63270
63271
63272
63273
63275
63276
63277
63278
63280
63281
63282
63283
63285
63286
63287
63290
63295
63300
63301
63302
63303
63304
63305
63306
63307
63308
63700
63702
63704
63706
63707
63709
63710
63740
64755
64760
64809
64818
64866
64868
65273
65760
65765
65767
65771
65780
65781
65782
69090
69155
69535
69554
69950
71552
72159
72198
73225
74263
75571
75952
75953
75954
75956
75957
75958
75959
76140
76496
76497
76498
78267
78268
78351
80100
80101
80104
80502
81200
81205
81206
81207
81208
81209
81210
81211
81212
81213
81214
81215
81216
81217
81220
81221
81222
81223
81224
81225
81226
81227
81228
81229
81240
81241
81242
81243
81244
81245
81250
81251
81255
81256
81257
81260
81261
81262
81263
81264
81265
81266
81267
81268
81270
81275
81280
81281
81290
81291
81292
81293
81294
81295
81296
81297
81298
81299
81300
81301
81302
81303
81304
81310
81315
81316
81317
81318
81319
81327
81330
81331
81332
81340
81341
81342
81350
81355
81370
81371
81372
81373
81374
81375
81376
81377
81378
81379
81380
81381
81382
81383
81400
81401
81402
81403
81404
81405
81406
81407
81408
81413
81414
81422
81439
81508
81511
81539
82075
82962
83987
84145
84410
84431
84793
86079
86305
86352
86780
86825
86826
86890
86891
86910
86911
86927
86930
86931
86932
86960
86985
87150
87153
87493
87903
87904
88000
88005
88007
88012
88014
88016
88020
88025
88027
88028
88029
88036
88037
88040
88045
88099
88125
88333
88334
88738
88749
89250
89251
89253
89254
89255
89257
89258
89259
89260
89261
89264
89268
89272
89280
89281
89290
89291
89300
89310
89320
89321
89322
89325
89329
89330
89331
89335
89342
89343
89344
89346
89352
89353
89354
89356
89398
90281
90283
90284
90287
90379
90384
90386
90389
90396
90586
90633
90634
90644
90647
90648
90653
90654
90665
90670
90696
90698
90700
90701
90702
90710
90718
90723
90739
90743
90744
90748
90816
90817
90818
90819
90821
90822
90823
90824
90826
90827
90828
90829
90845
90865
90875
90876
90880
90885
90889
90901
90911
90940
90989
90993
90997
90999
91132
91133
92314
92315
92316
92317
92325
92352
92353
92354
92355
92358
92371
92531
92532
92533
92534
92540
92548
92550
92559
92560
92561
92562
92564
92570
92630
92633
92970
92971
92975
92992
92993
93583
93660
93770
93784
93786
93788
93790
94005
94011
94012
94013
94015
94774
94775
94776
94777
95052
95120
95125
95130
95131
95132
95133
95134
95824
95965
95966
95967
95992
96000
96001
96002
96003
96004
96150
96151
96152
96153
96154
96155
96160
96161
96376
96567
96902
96904
97169
97170
97171
97172
97537
97545
97546
97597
97598
97602
97605
97606
97755
97810
97811
97813
97814
98940
98941
98942
98943
98960
98961
98962
98966
98967
98968
98969
99000
99001
99002
99024
99026
99027
99050
99051
99053
99056
99058
99060
99071
99075
99078
99080
99082
99090
99091
99100
99116
99135
99140
99151
99152
99153
99155
99156
99157
99172
99177
99184
99190
99191
99192
99199
99251
99252
99253
99254
99255
99288
99304
99305
99306
99307
99308
99309
99310
99315
99316
99318
99324
99325
99326
99327
99328
99334
99335
99336
99337
99339
99340
99341
99342
99343
99344
99345
99347
99348
99349
99350
99354
99355
99356
99357
99358
99359
99360
99374
99375
99377
99378
99379
99380
99401
99402
99403
99404
99406
99408
99409
99411
99412
99429
99441
99442
99443
99444
99446
99447
99448
99449
99450
99455
99456
99462
99466
99467
99468
99469
99471
99472
99475
99476
99477
99478
99479
99480
99499
99500
99501
99502
99503
99504
99505
99506
99507
99509
99510
99511
99512
99600
99601
99602
99605
99606
99607
603 Payable Level II HCPCS Codes
The following Level II HCPCS codes represent services that are covered by MassHealth when provided by AOHs, including hospital-licensed health centers (HLHCs) and other satellite clinics.
A4261
A4266
A4267
A4268
A4269
A4641
A4648
A9500
A9502
A9503
A9505
A9512
A9537
G0105
G0108
G0109
G0121
G0270
G0271
G0279
G0378
G0379
G0424
G6001
through
G6015
J0129
J0131
J0135
J0153
J0171
J0207
J0215
J0221
J0256
J0257
J0290
J0295
J0348
J0456
J0461
J0475
J0476
J0490
J0558
J0561
J0570
J0571
J0572
J0573
J0574
J0575
J0585
J0586
J0587
J0588
J0592
J0597
J0598
J0638
J0640
J0690
J0694
J0696
J0697
J0702
J0715
J0718
J0775
J0780
J0833
J0834
J0840
J0881
J0882
J0885
J0887
J0888
J0897
J1020
J1030
J1040
J1055
J1056
J1071
J1094
J1100
J1130
J1160
J1170
J1200
J1260
J1290
J1300
J1320
J1322
J1438
J1439
J1440
J1441
J1460
J1557
J1559
J1561
J1562
J1566
J1569
J1571
J1580
J1599
J1626
J1630
J1650
J1655
J1670
J1710
J1720
J1725
J1740
J1743
J1745
J1750
J1786
J1790
J1800
J1826
J1885
J1890
J1942
J1950
J1956
J1990
J2060
J2150
J2175
J2182
J2248
J2250
J2265
J2270
J2274
J2300
J2310
J2315
J2323
J2355
J2357
J2358
J2405
J2430
J2440
J2469
J2503
J2505
J2507
J2510
J2515
J2550
J2560
J2562
J2675
J2680
J2704
J2760
J2778
J2785
J2786
J2788
J2790
J2792
J2793
J2794
J2796
J2820
J2840
J2910
J2916
J2920
J2930
J2940
J2941
J3010
J3030
J3095
J3110
J3121
J3145
J3230
J3240
J3243
J3250
J3262
J3301
J3302
J3303
J3357
J3360
J3385
J3396
J3410
J3411
J3430
J3487
J3490
J3590
J7030
J7060
J7070
J7131
J7181
J7182
J7200
J7201
J7303
J7304
J7307
J7309
J7312
J7320
J7321
J7322
J7323
J7324
J7325
J7326
J7327
J7336
J7342
J7599
J7608
J7614
J7620
J7626
J7633
J7639
J7644
J7665
J7669
J7676
J7682
J7686
J7699
J7799
J8561
J8562
J9000
J9001
J9002
J9025
J9031
J9035
J9040
J9041
J9043
J9045
J9055
J9060
J9130
J9155
J9171
J9178
J9179
J9181
J9190
J9201
J9202
J9206
J9212
J9213
J9214
J9215
J9216
J9217
J9218
J9219
J9228
J9250
J9260
J9261
J9263
J9264
J9266
J9267
J9293
J9300
J9301
J9302
J9305
J9307
J9310
J9315
J9340
J9351
J9355
J9360
J9370
J9390
J9395
J9999
L8614
L8615
L8616
L8617
L8618
L8619
L8690
L8691
Q0081
Q0083
Q0084
Q4100
Q4101
Q4102
Q4103
Q4104
Q4105
Q4106
Q4107
Q4108
Q4110
Q4111
Q4112
Q4113
Q4114
Q4115
S0023
S0028
S0077
S0302
S2083
S3005
604 Modifiers
The following service code modifiers are allowed for billing under the MassHealth Acute Outpatient Hospital Manual for payable services.
Modifier Description
22 Increased procedural services
24 Unrelated evaluation and management service by the same physician during a postoperative period
25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service
27 Multiple outpatient hospital E/M encounters on the same date
50 Bilateral procedure
51 Multiple procedures
52 Reduced services
53 Discontinued procedure
57 Decision for surgery
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period
59 Distinct procedural service
63 Procedure performed on infants less than 4 kg
73 Discontinued outpatient procedure prior to anesthesia administration
74 Discontinued outpatient procedure after anesthesia administration
76 Repeat procedure or service by same physician or other qualified health care professional
77 Repeat procedure or service by another physician or other qualified health care professional
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period
80 Assistant surgeon
90 Reference (outside) laboratory
91 Repeat clinical diagnostic laboratory test
99 Multiple modifiers
BL Special acquisition of blood and blood products
CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission
CR Catastrophe/disaster related
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
FA Left hand, thumb
FB Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples)
GA Waiver of liability statement issued as required by payer policy, individual case.
GG Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day
GH Diagnostic mammogram converted from screening mammogram on the same day
LC Left circumflex, coronary artery
LD Left anterior descending coronary artery
LT Left side (used to identify procedures performed on the left side of the body)
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
QM Ambulance service provided under arrangement by a provider of services
QN Ambulance service furnished directly by a provider of services
RC Right coronary artery
RT Right side (used to identify procedures performed on the right side of the body)
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great digit
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
TA Left foot, great toe
U5 Medicaid level of care 5, as defined by each state
U6 Medicaid level of care 6, as defined by each state
U7 Medicaid level of care 7, as defined by each state
U8 Medicaid level of care 8, as defined by each state
U9 Medicaid level of care 9, as defined by each state
XE Separate Encounter: a service that is distinct because it occurred during a separate encounter
XP Separate Practitioner: a service that is distinct because it was performed by a different practitioner
XS Separate Structure: a service that is distinct because it was performed on a separate organ/structure
XU Unusual Non-Overlapping Service: the use of a service that is distinct because it does not overlap usual components of the main service
Modifiers for Behavioral Health Screening
The administration and scoring of standardized behavioral health screening tools selected from the approved menu of tools found in Appendix W of your MassHealth provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. Service Code 96110 must be accompanied by one of the modifiers listed below to indicate whether a behavioral health need was identified. “Behavioral health need identified” means the provider administering the screening tool, in
her or his professional judgment, identified a child with a potential behavioral health services need.
U1 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your MassHealth provider manual with no behavioral health need identified.
U2 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your MassHealth provider manual and behavioral health need identified.
Modifiers for Perinatal Depression Screening (effective for dates of service on or after May 16, 2016)
Service Code S3005 must be used by acute outpatient hospitals when billing MassHealth for the administration and scoring of a MassHealth-approved standardized perinatal depression screening tool. The code must be accompanied by one of the modifiers listed below.
U1 Perinatal care provider completed prenatal or postpartum depression screening and behavioral health need identified (positive screen)
U2 Perinatal care provider completed prenatal or postpartum depression screening with no behavioral health need identified (negative screen)
U3 Pediatric provider completed postpartum depression screening during well-child or infant episodic visit and behavioral health need identified (positive screen)
U4 Pediatric provider completed postpartum depression screening during well-child or infant episodic visit with no behavioral health need identified (negative screen)
Please refer to the Massachusetts Department of Public Health’s (DPH) postpartum depression (PPD) screening tool grid for any revisions to the list of MassHealth-approved screening tools:
eohhs/gov/departments/dph/programs/family-health/postpartum-depression/postpartum-depression-tools.html.
Modifiers for Tobacco-Use Cessation Services
The following modifiers are used in combination with Service Code 99407 to report tobacco-use cessation counseling. Service Code 99407 (Smoking- and tobacco use-cessation counseling visit; intensive, greater than 10 minutes) may also be billed without a modifier to report an individual smoking- and tobacco-cessation counseling visit of at least 30 minutes.
HQ Group counseling, at least 60-90 minutes
TF Intermediate level of care, at least 45 minutes
Modifier for Child and Adolescent Needs and Strengths (CANS)
HA Service Code 90791 must be accompanied by this modifier to indicate that the Child and Adolescent Needs and Strengths is included in the assessment. This modifier may be billed only by psychiatrists.
Modifiers for Provider Preventable Conditions That Are National Coverage Determinations
PA Surgical or other invasive procedure on wrong body part
PB Surgical or other invasive procedure on wrong patient
PC Wrong surgery or other invasive procedure on patient
For more information on the use of these modifiers, see Appendix V of your provider manual.
605 Revenue Codes
The following table lists the revenue codes that acute outpatient hospitals (AOHs), including hospital-licensed health centers and other provider-based satellites, use when billing for MassHealth-covered services. Please refer to the current edition of the Ingenix Uniform Billing Editor as a guide to determine the most common revenue HCPC code mappings. To purchase the application, go to .
|Revenue Code |Description |
|025X Pharmacy |
|0250 |General |
|0251 |Generic drugs |
|0252 |Nongeneric drugs |
|0253 |Take-home drugs |
|0254 |Drugs incident to other diagnostic services |
|0255 |Drugs incident to radiology |
|0257 |Nonprescription drugs |
|0258 |IV solutions |
|026X IV Therapy |
|0260 |General |
|027X Medical/Surgical Supplies and Devices – General |
|0270 |General |
|0271 |Nonsterile supply |
|0272 |Sterile supply |
|0273 |Take-home supplies |
|0274 |Prosthetic/orthotic devices |
|0275 |Pacemaker |
|0276 |Intraocular lens |
|0278 |Other implants |
|028X Oncology |
|0280 |General |
|029X DME |
|0290 |General |
|0291 |Rental |
|0292 |Purchase of new DME |
|0293 |Purchase of used DME |
|030X Laboratory |
|0300 |General |
|0301 |Chemistry |
|0302 |Immunology |
|0304 |Nonroutine dialysis |
|0305 |Hematology |
|0306 |Bacteriology and microbiology |
|0307 |Urology |
|0309 |Other |
|031X Laboratory Pathological – General |
|0310 |Laboratory pathological – general |
|0311 |Cytology |
|0312 |Histology |
|0314 |Biopsy |
|0319 |Other |
|032X Radiology - Diagnostic |
|0320 |General |
|0321 |Angiocardiography |
|0322 |Arthrography |
|0323 |Arteriography |
|0324 |Chest X ray |
|0329 |Other |
|033X Radiology – Therapeutic and/or Chemotherapy Administration |
|0330 |General |
|0331 |Chemotherapy administration – injected |
|0332 |Chemotherapy – oral |
|0333 |Radiation therapy |
|0335 |Chemotherapy administration – IV |
|034X Nuclear Medicine |
|0340 |General |
|0341 |Diagnostic |
|0342 |Therapeutic |
|0343 |Diagnostic radiopharmaceuticals |
|0349 |Other |
|035X Computerized Tomographic (CT) Scans |
|0350 |General |
|0351 |Head scan |
|0352 |Body scan |
|0359 |Other |
|036X Operating Room Services |
|0360 |General |
|0361 |Minor surgery |
|037X Anesthesia |
|0370 |General |
|0371 |Anesthesia incident to radiology |
|0372 |Anesthesia incident to other diagnostic services |
|038X Blood |
|0381 |Packed red blood cells |
|0383 |Plasma |
|0384 |Platelets |
|0385 |Leukocytes |
|0386 |Other components |
|0387 |Other derivatives |
|039X Blood Storage and Processing |
|0390 |General |
|0391 |Administration |
|040X Other Imaging Services |
|0400 |General |
|0401 |Diagnostic mammography |
|0402 |Ultrasound |
|0403 |Screening mammography |
|0404 |Positron emission tomography (PET) |
| |
|041X Respiratory Services |
|0410 |General |
|0412 |Inhalation services |
|0413 |Hyperbaric oxygen therapy |
|0419 |Other |
|042X Physical Therapy |
|0420 |General |
|0421 |Visit charge |
|0423 |Group charge |
|0424 |Evaluation or reevaluation |
|043X Occupational Therapy |
|0430 |General |
|0431 |Visit charge |
|0433 |Group rate |
|0434 |Evaluation or reevaluation |
|044X Speech-Language Pathology |
|0440 |General |
|0441 |Visit charge |
|0443 |Group rate |
|0444 |Evaluation or reevaluation |
|045X Emergency Room |
|0450 |General |
|0456 |Urgent care |
|0459 |Other ER |
|046X Pulmonary Function |
|0460 |General |
|0469 |Other |
|047X Audiology |
|0470 |General |
|0471 |Diagnostic |
|0472 |Treatment |
|0479 |Other |
|048X Cardiology |
|0480 |General |
|0481 |Cardiac catheterization lab |
|0482 |Stress test |
|0483 |Echocardiology |
|0489 |Other |
|049X Ambulatory Surgical Care |
|0490 |General |
|0499 |Other |
|051X Clinic |
|0510 |General |
|0514 |OB/GYN |
|0515 |Pediatric clinic |
|0519 |Other |
|053X Osteopathic Services |
|0530 |General |
|061X Magnetic Resonance Technology |
|0610 |General |
|0611 |MRI – brain |
|0612 |MRI – spinal cord |
|062X Medical/Surgical Supplies |
|0621 |Supplies incident to radiology |
|0622 |Supplies incident to other diagnostic services |
|063X Pharmacy |
|0634 |EPO, less than 10,000 units |
|0635 |EPO, 10,000 or more units |
|0636 |Drugs requiring detail coding |
|0700 |General |
|071X Recovery Room |
|0710 |General |
|072X Labor Room/Delivery |
|0720 |General |
|0721 |Labor |
|0722 |Delivery |
|073X EKG/ECG |
|0730 |General |
|0731 |Holter monitor |
|0732 |Telemetry |
|074X EEG |
|0740 |General |
|075X Gastroenterology |
|0750 |General |
|760X Treatment/Observation Room |
|0761 |Treatment room |
|0762 |Observation room |
|077X Preventive Services |
|0771 |Vaccine administration |
|082X Hemodialysis |
|0820 |General |
|0821 |Hemodialysis composite/other rate |
|0825 |Support Services |
|083X Peritoneal Dialysis |
|0830 |General |
|0831 |Peritoneal composite/other rate |
|0835 |Support Services |
|084X CAPD |
|0840 |General |
|0841 |CAPD composite/other rate |
|0845 |Support Services |
|085X CCPD |
|0850 |General |
|0851 |CCPD composite/other rate |
|0855 |Support Services |
| |
|090X Behavioral Health Treatments/Services |
|0900 |General |
|0901 |Electroshock therapy |
|091X Behavioral Health Treatments/Services |
|0914 |Individual therapy |
|0918 |Testing |
|092X Other Diagnostic Services |
|0920 |General |
|0921 |Peripheral vascular lab |
|0922 |Electromyelogram |
|0924 |Allergy testing |
|0929 |Other diagnostic service |
|094X Other Therapeutic Services |
|0940 |General |
|0942 |Education/training |
|0943 |Cardiac rehabilitation |
|0944 |Drug rehabilitation |
|0945 |Alcohol rehabilitation |
This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS are defined in the CPT 2017 codebook.
This page is reserved.
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